Home away from home.

Ronald McDonald House Charities of Oregon & Southwest Washington

Patient Information

* Patient Name ( First and Last )

Patient Preferred Name

Patient Preferred Pronouns

* Patient Date of Birth (MM/DD/YYYY)

For Fetal Care patients, please put the child’s expected date of delivery

* Patient Gender

* Diagnosis

* Reason For Stay

* Patient is being treated at:

* Department

* Social Worker/Care Management: (To add a new person, choose "Other")

Physician/Doctor

* Will the patient be inpatient or outpatient?

Inpatient - Hospitalized Outpatient - Non-Hospitalized Both, during this stay.

Medicaid Information

While Ronald McDonald House Charities RMHC does not charge a fee or ask families to pay for their stay, we do work closely with state Medicaid to obtain lodging reimbursement for a family's stay. This funding helps RMHC ensure families are able to stay at no cost. If the patient is still in utero, the parents medicaid information can be entered in.

* Medicaid Coordinated Care Organization/Transportation Brokerage (If no Medicaid, choose "No Medicaid")

* Medicaid Branch (If patient does not have Medicaid, choose "No Medicaid")

Reservation Request

* Date of first appointment at hospital

* Check In Date

* Check Out Date

Guardian Contact Information

* Guardian/Caregiver Name (First and Last)

Guardian Preferred Name

Guardian Preferred Pronouns

* Guardian/Caregiver Gender

* Date of Birth (MM/DD/YYYY)

* Relationship to patient

* Primary Phone Number

* Do you consent to the guest service team contacting you via text? (message and data rates may apply)

* Email

Second Guardian/Caregiver Name (First and Last)

Guardian 2 Preferred Name

Guardian 2 Preferred Pronouns

Guardian/Caregiver Gender

Date of Birth (MM/DD/YYYY)

Relationship to patient

Primary Phone Number

Do you consent to the guest service team contacting you via text? (message and data rates may apply)

Additional Guests / Family Members: Add Another Guest

Additional Information

Primary Language

U.S. / Canadian Postal Code lookup

* Country

* Address

City/Villa/Town

County/District

Zip

Please enter the name and phone number of someone who is NOT going to be staying at the Ronald McDonald House.

* Emergency / Additional Contact name

* Emergency / Additional Phone

Car Make/Model/Description

Car License State

License Plate#

* Will the family be bringing a service dog? (companion and emotional support dogs do not qualify as service animals and are not allowed at our Houses)

No Yes

* Does the family require an ADA Room?
We will do our best to accomodate, this is not guaranteed. Please reach out to the guest service team to check on availability after you submit your request. Bend.house@rmhcoregon.org.

Comments / Additional Needs